Provider First Line Business Practice Location Address:
3300 POPLAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47803-2340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-235-6281
Provider Business Practice Location Address Fax Number:
812-235-9305
Provider Enumeration Date:
06/21/2005